Family Autobiographical Information Child Foster Care Seniors and People with Disabilities Children with Developmental Disabilities A separate form should be filled out by each son and daughter, 9 to 13 years of age, who is living at home with the Applicant and Co-Applicant. These next few pages are for you to fill out. Please answer these questions as honestly as you can, in your own handwriting. It s okay to get some help form your parents filling out these pages. After you have completed the form, please mail it back to the certifier in the attached envelope. Thanks. Age: Address: Street City State Zip 1. Please list five words that describe your personality. A. B. C. D. E. 2. Please describe some of the ways that you are different from each of your parents: 3. Please describe some of the ways that you are like each of your parents. 4. What are some of your favorite activities that you like doing, just for fun? Page 1 of 6 SDS 4524 (03/05)
5. What are the tasks, or chores, that you are responsible for doing in your home? Do you usually do your chores on you own, or do you need to be reminded to get them done? 6. Describe some of the activities that you like to do with your parents: 7. In your family, who are the people that you tend to get along with the best? 8. In your family, who are the people that you tend to have the most arguments or confrontations with? 9. Please describe what you would like to change most about yourself and why. How would you accomplish these changes? 10. Please describe any special activities that you are involved with: Page 2 of 6 SDS 4524 (03/05)
11. Would you be willing to include a child placed in you family home in any of these activities? 12. Describe the type of discipline that your parents use with you. Please explain if it is effective. 13. What sort of things are you usually disciplined for, and which person usually does the disciplining in your family? 14. What school do you attend? What grade are you in? 15. What do you like best, and least about school? 16. Do you like to be with one best friend, a few friends, lots of friends, or do you mostly just like to spend time by yourself? Page 3 of 6 SDS 4524 (03/05)
17. Are most of your friends your own age, or they are younger or older than you are? 18. Describe what sorts of things tend to upset you, and what you do when you are upset: 19. Describe what part you have in making the decisions that affect your family: 20. How much time do you get your parents all to yourself? Do you have to share them a lot with the rest of the family, or with friends? 21. What are some of the other things that you have to share with other people now? 22. What do you think are some of the things that you will have to share with a child who is placed in your family home for foster care? Page 4 of 6 SDS 4524 (03/05)
23. How do you feel about having to share those things? 24. What are the things that are special to you that you will not want to have to share with someone else? 25. In what ways would you enjoy being a brother or a sister to a child placed in your home for foster care? 26. What do you think will be the hardest part, for you, about having a child living in your home for foster care? What effect do you think it will have on you? 27. Please describe what you would say to a friend, who said, I never heard of foster care. What is it? Page 5 of 6 SDS 4524 (03/05)
28. On this page, please draw a picture of your home. In your drawing, include yourself, your family, and the new child that may be coming to live with you for foster care. Thank you. Page 6 of 6 SDS 4524 (03/05)